Provider Demographics
NPI:1801991195
Name:ELLERMANN, GREGORY TIMOTHY (PHD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:TIMOTHY
Last Name:ELLERMANN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 EAST 55TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64113
Mailing Address - Country:US
Mailing Address - Phone:816-333-3262
Mailing Address - Fax:
Practice Address - Street 1:3515 S 4TH ST
Practice Address - Street 2:PROFESSIONAL ASSOCIATION
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048
Practice Address - Country:US
Practice Address - Phone:913-651-8415
Practice Address - Fax:913-772-8580
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS860103T00000X
MO01582103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS043080OtherBCBS OF KANSAS
7030764OtherAETNA
004517OtherBCBS OF KANSAS GROUP
KS32816022OtherKANSAS CITY BCBS